CPR Is Our System in Order. Presented by: Kathleen Patterson, RN, RAC-CT Pathway Health

CPR Is Our System in Order Presented by: Kathleen Patterson, RN, RAC-CT Pathway Health

Objectives On successful completion of this activity, the participant should be able to: Review the American Heart Association and Emergency Cardiovascular Guidelines Identify the risk of non-compliance Examine the steps to ensure that your organization is in compliance 2

LAWS, REGULATIONS AND RECOMMENDATIONS 3

CMS Memorandum Ref: S&C: 14-01-NH Cardiopulmonary Resuscitation(CPR) in Nursing Home. http://www.cms.gov/medicare/provider- Enrollment-and- Certification/SurveyCertificationGenInfo/Download s/survey-and-cert-letter-14-01.pdf Effective implementation 10/18/2013 4

Memorandum Summary Initiation of CPR- Prior to the arrival of (EMS) nursing home must provide basic life support Facility CPR- Facilities must not establish system wide no CPR policy Surveyor Implication-Review the response of the nursing home related to CPR 5

Background Federal regulations 42 C.F.R. 483.10 Provide that a resident of a skilled nursing facility or nursing facility has the right To a dignified existence Self determination Formulate an advanced directive 6

Background Federal regulations 42 C.F.R. 483.20 and 483.25 Services provided by the facility must meet the professional standards of quality Provide the necessary care and services to attain the highest practicable mental, physical and psychosocial well-being 7

American Heart Association Chain of Survival 8

Nursing Home Survival Unwitnessed arrest Poor staff response Lack of willingness to honor full code requests Lack of training Unaware of code status 9

Statistics 1/3 of all arrests in nursing homes are witnessed. 33% of residents that are full code do not receive CPR 20% who do receive CPR are resuscitated prior to the arrival of emergency personal Defibrillation and CPR are important due to the younger patients entering nursing homes. 10

CPR survival rate Nursing home survival rates are comparable to community CPR initiated in witnessed cardiac arrests EMS response time was similar 10.5 % of nursing home residents were discharged from hospital 9.2% community discharged from hospital 11

Obligation Yes Study of 346 nursing home 4% would not provide CPR 23% would not provide CPR but call EMS 15% would provide CPR with an advanced directive 57% would provide CPR in absence of advanced directive Burns,Kane (1997) 12

CPR Ready How often does you staff receive training Who is trained Policy for preforming CPR How long does it take EMS to arrive Is our crash cart in order Personal Pocket mask Automatic defibrillator 13

Case Study Refused to do CPR on a resident Stopped CPR- She dead anyway It s to late to start CPR I didn t even think about starting CPR even though she was a full code. 14

Case Study Resident: 44 year old female with a code status FULL RESUCITATION 15

Case Study- CPR F- 309 QUALITY OF CARE F-322- NASO-GASTRIC TUBE F- 323 ACCIDENT AND INJURY Provide necessary care and services to a resident when staff are not adequately trained Ensure that emergency equipment is stocked Assess and monitor resident for aspiration 16

Practice Practice Practice Is every two years enough??? Retention of skills begin to decline within 10 months. Knowledge and psychomotor skill declines significantly at 10 weeks and 12 months 17

Maintaining and retaining Yearly training On-site simulation lab Short practice session 3-6 minutes single CPR Practice skill independently Immediate feedback Oermann,Edgren,Maryon, Roberts (2014) 18

F155 - Advance Directives The Intent: To establish and maintain policies and procedures in the facility regarding these rights. To inform and educate residents about your policies/procedures and about how they can exercise their rights. To help/assist the resident in exercising their rights. To ensure that the resident choices are incorporated in their treatment, plan, care and services. 19

Tightening up Our Policy 1. Facilities are obligated to establish, maintain and implement written policies and procedures addressing: a. The resident s right to formulate an Advance Directive b. Right to refuse medical or surgical treatment c. The facility must ensure that the staff are following the policies and procedures d. Right to decline to participate in experimental research

Steps to Consider 1. On admission, is it determined that the resident has an Advance Directive or will choose to formulate one? Is this documented? 2. What formal system do you have identified in place to ensure that ongoing assessment of resident decision making ability is instituted in order to invoke decision making by a health care agent or legal representative if resident is unable to make their own decisions? 21

Steps to Consider 3. Identification and documentation of primary decision maker. 4. Defining and clarifying medical and health care issues when needed and as a part of the comprehensive care planning process, or with any significant change in status, reviewing existing wishes and discussing any preferred changes or modifications in approach. 5. Documentation and communication of choices to the Interdisciplinary Team. 22

Important Point The facility will want to identify a process (in accordance with State Law) to handle situations where the Facility and Physician do not feel that they can provide the care in accordance with the resident s advance directives or other wishes. 23

What MUST We Have in Place? 1. Written Policies and Procedures 2. Residents must receive written description of your Policies and Procedures. 3. On Admission, written information regarding the resident s rights to refuse medical treatment and the right to formulate an Advance Directive. 4. If the resident has formulated/executed an Advance Directive, it should be placed in the same section of the medical record for staff retrieval and communication with staff and physician. 24

What MUST We Have in Place cont.? 5. If the resident does not have an Advance Directive in place, the facility must Advise the resident/family of the right to establish an Advance Directive, Offer assistance in executing the Advance Directive if wishes and to document the process in the medical record. If the resident chooses to decline, they cannot be required to execute an Advance Directive. **The facility cannot discriminate or determine provision of care based on whether the resident has an Advance Directive. 6. The facility must provide education to the resident community on their rights to formulate an Advance Directive and the facilities policies and procedures. 25

Medical Director Involvement 26

Medical Director Involvement Tips for the Medical Director Involvement: The Medical Director can help staff and practitioners identify clinical conditions and risks pertinent to the facility s population. The Medical Director can provide guidance to nursing and other staff concerning when to contact him or her Review the medical and clinical appropriateness of the facility s direct-care practices. 27

Medical Director Involvement The Medical Director can participate in administrative decision-making and the development of policies and procedures related to patient care Monitoring and evaluating the quality and appropriateness of medical services as an integral part of the overall quality assessment and improvement program. 28

Medical Director Involvement The Medical Director can advise about clinical risk management concerns such as adverse drug reactions A Medical Director can help review and analyze quality data and clinical topics presented at QA meetings and can help identify trends, root causes and pertinent interventions. The Medical Director can provide specific guidance for physician performance expectations 29

Survey Ready 30

Guidance to Surveyor Immediate Jeopardy Harm Culpability Immediacy

Immediate Jeopardy Harm Actual- Has the provider s non-compliance caused serious injury, harm, impairment, or death to an individual Potential-Is the provider s non compliance likely to cause serious injury, harm, impairment or death 32

Immediate Jeopardy Immediacy Is the harm or potential harm likely to occur in the very near future to this individual or others in the entity, if immediate action is not taken 33

Immediate Jeopardy Culpability Did the facility know about the situation? 34

Immediate Jeopardy Level 4 In which the facility has non-compliance with one or more issue Allowed, caused or likely to cause serious impairment or death to a resident Requires immediate correction as the facility has allowed the situation to continue 35

Severity level 3 Non-compliance that is not immediate Non-compliance that resulted in actual harm Clinical compromising or decline Inability to reach highest practicable wellbeing 36

Severity Level 2 No actual harm, minimal harm, no immediate jeopardy Resident has minimal discomfort Compromised resident well-being Harm may occur if interventions not provided 37

Sub-standard quality of care Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.13, resident behavior and facility practices,42 CFR 483.15, quality of life, or 42 CFR 483.25, quality of care, that constitute either immediate jeopardy to resident health or safety (level J, K, or L); a pattern of or widespread actual harm that is not immediate jeopardy (level H or I); or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm (level F). (42 CFR 488.301) 38

Sub-standard quality of care Substantial compliance means a level of compliance with the requirements of participation such that any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm. Substantial compliance constitutes compliance with participation requirements. (42 CFR 488.301) 39

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Sub-standard quality of care Whenever a facility has deficiencies that constitute both immediate jeopardy to resident health or safety and substandard quality of care (as defined in 42 CFR 488.301), the survey agency must notify the attending physician of each resident found to have received substandard quality of care as well as the State board responsible for licensing the facility s administrator. Notify physicians and the administrator licensing board in accordance with 7320. 41

Memorandum Summary Initiation of CPR- Prior to the arrival of (EMS) nursing home must provide basic life support Facility CPR- Facilities must not establish system wide no CPR policy Surveyor Implication-Review the response of the nursing home related to CPR 42

Solutions 43

Immediate Solutions 1. Review current systems for each regulation to identify system updates necessary (i.e. policies/procedures, protocols, etc.) and develop an Action Plan 2. Update all Policies and Procedures to be consistent with the regulations (Quality Assurance, QAPI) 3. All Staff Education regarding each system/process with system to verify competence/understanding 44

Immediate Solutions 4. Implement the System! 5. Implement a monitoring/audit component to verify compliance with the system. 6. Follow up for any opportunities for improvement! 45

Solutions Provide a opportunity for staff to practice CPR on a quarterly basis (3-6 minutes). Develop scenario's for each shift Complete a table top exercise for each scenario Practice Practice Practice Promote training of all licensed and non-licensed nursing staff. 46

Audit System An effective Audit System will be one that is: 1. Formal 2. Organized 3. Completed as Planned 4. Data is utilized to improve/maintain quality and can be used to benchmark over time. 47

YOU CAN DO IT! 48

References and Websites http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert- Letter-13-35.pdf http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Federal-Regulatory- Group-LTC.pdf http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and- Regions.html http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and- Regions-Items/Survey-and-Cert-Letter-13-16.html?DLPage=1&DLFilter=dir&DLSort=3&DLSortDir=descending http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/som107c07.pdf pages 107-108. 49

References and Websites Oermann,M.,Edgren-Kardong,S.,Odom-Maryon,T., Roberts,C.,(2014) Effects of practice on competency in singlerescuer cardiopulmonary resuscitation[electronic version]. Journal of MedSurg Nursing,23(1),1-22 Williams,D.,Calder,S.,Cocchi,M.,Donnino,M.,(2013) From door to recovery: A collaborative approach to the development of a post-cardiac arrest center[electronic version]. Critical Care Nurse,33(5),42-55 50

Thank You Pathway Health Services 1-877-777-5463 www.pathwayhealth.com 51